Professionalism in Medicine

Jill Thistlethwaite, Dr John Spencer

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315357997
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Those at the grassroots of primary care have been provided with a unique opportunity to plan and shape the modern NHS. This book describes the work of primary care groups in their first months and describes everything from the initial aims of PCGs through to primary care trusts and the future. The excellent panel of contributors who are practised members of PCGs describe their experiences and the lessons they have learnt. The book explores how organisations will evolve and provides guidance on theory people and functions. It is essential reading for members of PCG teams and those with or aspiring to PCT status.

CHAPTER 1

The context

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This chapter explores:

• the historical context
• what’s in a word - definitions of professionalism
• the origins of the recent interest in professionalism
• the UK experience
• developments in North America
• trust in doctors
• patient-centred professionalism.

A professional is a man who can do his job when he doesn't feel like it. An amateur is a man who can't do his job when he does feel like it.¹

James Agate (1877–1947), British diarist and critic

Historical Context

Doctors have been considered ‘professionals’ for as long as the concept of a profession has existed. Since Hippocrates’ time in Western cultures, and for at least as long in Oriental cultures (e.g. China), doctors have held a special place in their communities, operating through an implicit social contract. In return for deploying their special (and usually carefully guarded) knowledge and skills, and being seen to act in a principled manner in the best interests of their patients, the privilege of autonomy and the freedom to self-regulate was bestowed upon them, as well as considerable social status. This arrangement endured for millennia, essentially unquestioned until well into the twentieth century, notwithstanding periodic assaults and critical analyses by sociologists, anthropologists, politicians, academics and patient/consumer groups. Nonetheless, the potential for doctors to act in an unethical manner and abuse their powerful status, or to act incompetently and harm patients but get away with it, was well recognised by both satirists (the famous line in George Bernard Shaw’s play A Doctor’s Dilemma, ‘All professions are a conspiracy against the laity’,² comes to mind) and philosophers (e.g. Ivan Illich in his scathing attack on medicine and the medical profession for the ‘expropriation of health’ in the mid-1970s³). However, it has only really been in the last 10 years or so that professionalism has come under intense scrutiny and stimulated such wide-ranging and far-reaching debate. Some of the reasons why this is so are briefly explored in this chapter, but first … what’s in a word?

What’s in a Word?

As most authors on the subject observe, one of the problems bedevilling discussion about ‘professionalism’ is its definition. The word is full of nuance and, as with such words as ‘love’ or ‘quality’, perhaps each of us is clear what we understand by the term, but we find it difficult to articulate. In fact definitions of professionalism abound, and some of the more important ones that have emerged recently are discussed in this chapter (Hilton and Slotnik of St George’s Medical School, London, suggested the most pithy to date, namely ‘A reflective practitioner who acts ethically’⁴). However, if only to marvel at the richness of language, it is worth considering how the concepts of ‘profession’ and ‘professional’ may be understood by the general public. Many people would see a ‘professional’ as being the opposite of an ‘amateur’ – for example, in music or sport, in which context the professional is usually thought to have skills superior to those of the amateur, and is of course paid to perform or to compete. However, there was also the notion of the ‘gentleman amateur’ – the sportsman who did not sully himself by being paid to perform, unlike the professional who took money and thus demeaned the spirit of sportsmanship. A soldier or a killer may also be described as ‘professional’, which here implies carrying out a job with calculated efficiency without fuss or emotion. Interestingly, the word ‘clinical’ is sometimes also used in this context. Finally, a footballer or rugby player will be cautioned for committing a ‘professional foul’, a ‘deliberate act of foul play, usually to prevent an opponent scoring.’⁵

Why the Recent Interest in Medical Professionalism?

Recent interest in medical professionalism, at least in the UK, dates back to the early 1990s. It could be argued that reform in undergraduate medical education, led as it was by the General Medical Council through its 1993 recommendations, Tomorrow’s Doctors,⁶ helped to catalyse thinking in this area. Although the word ‘professionalism’ was not used in the document, the principles were implicit – for example, with increased emphasis on communication skills, ethical reasoning, the development of appropriate attitudes, and so on. The recommendations and the visits that followed empowered educators in medical schools, previously marginalised, to develop teaching, learning and assessment in relevant areas, and raised awareness about the need to address these issues effectively and systematically.

In 1994, Sir Kenneth Caiman, then Chief Medical Officer, published a paper in the British Medical Journal in which he argued that it was timely to consider the nature of professionalism, in the light of ‘increasing public and professional interest in medicine, and a questioning of professional standards and the quality of care.’⁷ He acknowledged that it was not easy to define ‘a profession’, but suggested that it was likely to have all or most of the characteristics listed in Box 1.1.

Box 1.1 Characteristics of a Profession⁷

• Driven by a sense of vocation or calling, implying service to others.
• Has a distinctive knowledge base, which is kept up to date.
• Sets its own standards and controls access through examination.
• Has a special relationship with those whom it serves.
• Is guided by particular ethical principles.
• Is self-regulating and accountable.

Caiman offered a statement about what kind of doctors society needs and the requisite underlying attitudes and competencies. In essence he argued that ‘Doctors need to have a broad vision of the world and be able to change and adapt as the knowledge base changes. They need to have outside interests and be rounded people, with breadth as well as depth.’⁷ For Caiman, the most important implication of all this was for medical education and training.

Later the same year, the British Medical Association (BMA) organised a ‘summit meeting’ of the profession’s leaders to debate medicine’s ‘core values’, and this was apparently the first such meeting for over 30 years.⁸ The need to revisit these values was presented in a no-nonsense fashion by Sir Maurice Shock, former Rector of Lincoln College, Oxford, who argued that the profession had failed thus far to appreciate the massive shift in societal attitudes which had occurred, particularly the advent of the ‘consumer society’, in the context of unprecedented medical advances and changing demography. He contended that ‘the doctor is different, the patient is different, and the medicine is different’ – indeed, ‘everything is different, except the way you organise yourselves.’⁸

The assembled great and good discussed six core values, namely confidence, confidentiality, competence, contract, community responsibility and commitment. One issue that taxed the participants was whether the doctor’s responsibility began and ended with the patient in the consulting room (the traditional view), or whether it extended to other patients, the community and the healthcare system, and beyond (a broader and more political view). After much debate, the list of core values was enhanced thus:

• commitment
• integrity
• confidentiality
• caring
• competence
• responsibility
• compassion
• spirit of enquiry
• advocacy.

A report of the summit meeting was duly published.⁹

Around the same time, the General Medical Council (GMC) was discussing proposals to shift the focus of its guidance to doctors away from a list of things that they must not do (the historic position, laid out in what was known as the ‘Blue Book’), to a description of what a good doctor should do. These guidelines were published as Duties of a Doctor¹⁰ and Good Medical Practice.¹¹ In Good Medical Practice (GMP), the GMC outlined ‘the principles and values on which good practice is founded’, and although the guidance was predominantly addressed to the profession, it was also intended to inform the public about what they should and could expect from their doctors. This signified a major change in the focus of thinking about the purpose of such guidance, although interestingly the actual word ‘professionalism’ was not used in the first edition.

The seven headings of Good Medical Practice will be familiar to most UK readers, having been adopted as the framework, among other things, for revalidation and appraisal, and the curriculum for the Foundation Programme for newly qualified doctors. The headings are shown in Box 1.2.

Box 1.2 The Seven Headings of Good Medical Practice¹¹

• Good clinical care
• Maintaining good medical practice
• Teaching and training, appraising and assessment
• Relationships with patients
• Working with colleagues
• Probity
• Health

The ‘bottom line’ of Good Medical Practice was that patients must be able to trust doctors with their lives and health, and that doctors should make the care of their patients their first priority.

Although Caiman’s paper, the BMA report and Good Medical Practice doubtless promoted debate and discussion, it is arguable that they had little impact on the ‘doctor on the Clapham omnibus.’ Sadly, that required the stimulus of external forces. The Bristol paediatric heart surgery scandal, news of which broke in early 1996 through the satirical magazine Private Eye, could be said to be the point at which the public and the Government really began to take an interest in professionalism. Other cases followed Bristol – for example, that of Rodney Ledward and Richard Neale, two wayward gynaecologists who were eventually struck off the GMC register on grounds of serious professional misconduct, and of course the mass-murdering GP Harold Fred Shipman.

The 1998 Bristol Inquiry, chaired by Professor Ian Kennedy, id...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Dedication Page
• Foreword
• About the authors
• 1 The context
• 2 Learning from history
• 3 The code of conduct: professionalism, law and ethics
• 4 Professional–patient relationships
• 5 Communication and its relationship with professionalism
• 6 Cultural diversity and competence
• 7 Professional knowledge and development: keeping up to date
• 8 Personal development and self-care
• 9 The nature of autonomy for the professional and the patient
• 10 Learning and teaching professionalism
• 11 Assessing professionalism
• 12 Professionalism and social justice: the next step?
• Index